Provider Demographics
NPI:1194811638
Name:MAH, FRED (OT)
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:
Last Name:MAH
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7405 N CEDAR AVE
Mailing Address - Street 2:103
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3838
Mailing Address - Country:US
Mailing Address - Phone:559-261-4100
Mailing Address - Fax:559-261-4101
Practice Address - Street 1:7405 N CEDAR AVE
Practice Address - Street 2:103
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3838
Practice Address - Country:US
Practice Address - Phone:559-261-4100
Practice Address - Fax:559-261-4101
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT6214225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADA6172OtherMEDICARE RAILROAD GROUP #
CAOT0062140OtherBLUE SHIELD OF CA. PIN
CAP00089881OtherMEDICARE RAILROAD INDIVIDUAL ID #
CADA6172OtherMEDICARE RAILROAD GROUP #
CAZZZ25912ZMedicare PIN